We fetch to your attention a new website where you can buy kamagra jelly australia at a low price with fast delivery to Australia.

Pps923.indd

Clinical Note Metacognitive Therapy versus Exposure and Response Prevention for Pediatric Obsessive-Compulsive Disorder A Case Series with Randomized Allocation
Michael Simons a Silvia Schneider b Beate Herpertz-Dahlmann a
a Department of Child and Adolescent Psychiatry, RWTH Aachen University, Aachen , Germany; b Clinical Child and Adolescent Psychology, University of Basel, Basel , Switzerland
Key Words
chotherapeutic alternative to the well-established ERP in
Child/adolescent obsessive-compulsive disorder ؒ
the treatment of pediatric OCD. Further investigations
into the effi cacy of MCT are necessary to answer ques-
Cognitive/metacognitive therapy ؒ Narrative therapy
tions as to the working mechanisms underlying therapy for OCD.
Abstract Background: Exposure with ritual prevention (ERP) is the psychotherapeutic treatment of choice for pediatric ob- Introduction
sessive-compulsive disorder (OCD). In the present study, a new treatment rationale – metacognitive therapy (MCT)
Obsessive-compulsive disorder (OCD) is a debilitating
for children – was developed and evaluated. Methods:
disorder with an estimated lifetime prevalence rate of
Ten children and adolescents with OCD were randomly
2–3% [1] . Besides pharmacotherapy with (selective) sero-
assigned to either MCT or ERP therapy condition. Pa-
tonin reuptake inhibitors [2] , cognitive-behavioral treat-
tients were assessed before and after treatment and at
ment (CBT) is the psychotherapy of choice for this disor-
the 3-month and 2-year follow-up by means of symptom
der, both for adults and young people. The empirically
severity interviews. Depressive symptoms were also as-
validated method is exposure with ritual prevention
sessed. Manualized treatment involved up to 20 sessions
(ERP) accompanied by cognitive and – in children and
on a weekly basis. Results: We found clinically and sta-
adolescents – by family interventions [3–5] . Until now,
tistically signifi cant improvements in symptom severity
there have been three controlled studies providing evi-
after treatment. At the 3-month and 2-year follow-up, the
dence for the efﬁ cacy of CBT (ERP) for pediatric OCD.
attained improvements during treatment were retained.
De Haan et al. [6] found a slight superiority of ERP over
Conclusions: Despite some methodological limitations,
pharmacotherapy (i.e., clomipramine), and Barrett et al.
results showed that MCT proved to be a promising psy-
[3] found no signiﬁ cant differences between individual
Department of Child and Adolescent Psychiatry
RWTH Aachen University, Neuenhofer Weg 21
Tel. +49 241 808 8260, Fax +49 241 808 2601, E-Mail [email protected]
and group cognitive-behavioral family treatment regard-
the contents of thoughts are discussed and examined with
ing efﬁ cacy and durability of treatment gains. In a very
regard to their truthfulness and probability [24] . In MCT,
recent study, the combination of CBT and pharmaco-
the focus does not lie on the content of obsessions and
therapy (i.e., sertraline) proved to be superior to CBT intrusive thoughts, but on the appraisal and the manage-alone and to sertraline alone [5] . The effectiveness of ERP
ment of these thoughts. These thoughts are normalized
is limited by high rates of treatment rejection and drop-
by simply accepting them. Furthermore, probability rat-
outs [7] . This strongly indicates that there is a need for a
ings (e.g. ‘How probable do you think it is that you could
psychotherapeutic alternative to ERP. Furthermore, the
contaminate your parents?’) are seldom useful in OCD
efﬁ cacy of ERP cannot be attributed solely to habituation
patients. Although they often know that the risk is very
[8] . In some cases, symptom reduction could be better low, they are not sure that they can take it. explained by cognitive changes or by changes in self-ef-
In psychoeducation, the patient’s speciﬁ c problem-
ﬁ cacy. This makes cognitive therapy a promising alterna-
maintaining metacognitive appraisals and strategies are
tive or additional treatment strategy [9] .
to be discovered, while the therapist emphasizes the nor-
New cognitive and metacognitive OCD models [10–
mality of these processes [10] . Socratic dialogue, thought
12] led to new intervention techniques – at least in the
control experiments, and behavioral experiments aim to
treatment of adult patients. Until now, there have been
change these metacognitive strategies and appraisals.
only a few case studies [13, 14] and a case series [15] ap-
Cottraux et al. [25] conducted one of the few studies
plying these new interventions to children and adoles-
that compare cognitive therapy and behavior therapy in
adult OCD. In the present study, the efﬁ cacy of MCT for children and adolescents with OCD was investigated. Ac-
cording to the Task Force criteria of the American Psy-
According to the cognitive model of Salkovskis and chological Association for the identiﬁ cation of empiri-
McGuire [16] and Wells’ metacognitive model [11, 12] ,
cally supported treatments [26] , MCT was tested against
obsessional thoughts develop from normal intrusive the already established ERP treatment. Both treatment thoughts that are interpreted and dealt with in special strategies were protocol driven according to two different ways. OCD patients tend to confuse these thoughts with
manuals written by the ﬁ rst author [22] . It was hypothe-
real actions, or events, or intentions (metacognitive mis-
sized that both treatment strategies would be effective at
interpretation) [17, 18] . They tend to make use of several
post-treatment and would have lasting effects after 3
dysfunctional metacognitive processes, such as increased
cognitive self-consciousness (‘too much thinking about thinking’) [19, 20] , thought suppression, and selective at-tention to further intrusive thoughts. Moreover, they often
are not sure when to stop the ritual, and make use of dys-
functional stop signals like ‘emotional reasoning’ (e.g. they
Eleven children and adolescents (7 males and 4 females) with
have to repeat the ritual until they ‘feel’ safe or clean).
OCD, aged 8–17 years, participated in the study. All were treated
These various metacognitive appraisals (e.g. thought-
in a child and adolescent psychiatric outpatient setting and were
action fusion) and metacognitive processes (thought con-
assigned either to narrative ERP or to MCT by simple randomiza-tion. One (male) patient dropped out of MCT, as it demanded too
trol strategies, selective attention) can be understood as
much self-reﬂ ection on his part. He was successfully treated with
dysfunctional solutions which lead to further exacerba-
ERP but excluded from further calculations. None of the remaining
tions of the vicious cycle of OCD. Recently, Mather and
10 patients (n = 5 in each group) received pharmacotherapy against
Cartwright-Hatton [21] have found these metacognitions
to be good predictors of obsessive-compulsive symptoms
All participants were diagnosed according to the DSM-IV/ICD-
10 diagnosis of OCD based on the German structured clinical in-
in adolescents and proposed a more metacognitively en-
terview ‘Kinder-DIPS’ [27] with the patients and their families and
on the well-established clinical interview Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Patients were excluded
if they had a diagnosis of mental retardation, autism, psychosis,
Metacognitive therapy (MCT) aims to change dys-
and current treatment using pharmacotherapy for OCD.
Five patients had one or more comorbid diagnoses, including
functional metacognitive appraisals and strategies. The agoraphobia (n = 2), Tourette’s syndrome (n = 1), chronic tic dis-
new term ‘metacognitive therapy’ [22, 23] marks the ma-
order (n = 2), and attention deﬁ cit hyperactivity disorder (ADHD)
jor differences to standard cognitive therapy. In the latter,
Table 1. Details of obsessive-compulsive psychopathology and metacognitive therapy suggestions for the ﬁ ve MCT patients
Behavioral experiment: Use unﬂ avoured
Thought-event fusion (‘thinking this thought increases the risk that it comes true’)
Thought-imperative defusion: you cannot do everything that you think ofMetacognitive reframing (you could not suffer from these thoughts unless God is very important to you)
ERP = Exposure with ritual prevention.
All instruments were administered by the therapists at pretreat-
The primary outcome was a change in OCD symptom severity,
ment, post-treatment, 3 months and 2 years after the completion
measured with the CY-BOCS. The CY-BOCS is a clinician-rated
of the therapy. At the 2-year follow-up, the clinical status regarding
scale with two subscales (obsessions and compulsions). In each sub-
OCD was assessed using a structured psychiatric interview for the
scale, frequency, interference, distress, resistance (to obsessions/
parents and the child (Kinder-DIPS) [27] . At the time of the last
compulsions), and control are rated. The total score ranges from 0
assessment, all interviews were performed by two experienced child
to 40. Scahill et al. [28] found good reliability and validity for the
and adolescent psychiatrists who were blinded to the patient’s treat-
CY-BOCS. A recent study [29] found the two resistance items to
be unreliable. This is in accordance with the metacognitive theory claiming that resistance to obsessions maintains obsessive-compul-
All patients received up to 20 treatment sessions on a weekly
The second outcome was a change in severity of depressive
basis provided mainly by the ﬁ rst author. Treatment was ﬁ nished
symptoms (self-rating), assessed using the German version of the
before the twentieth sessions if according to the estimation of both
Children’s Depression Inventory (CDI) [30] . The authors of the
therapist and patient treatment goals were already met before. Par-
German version [31] report good reliability and validity. The 26
ents were generally included in the therapy sessions except in cases,
items are scored on a 3-point scale. In the present study, the stan-
where the (older) adolescents did not permit it. There were no par-
Metacognitive Therapy for Pediatric OCD
Table 2. Demographic and clinical
1 Mann-Whitney U-Test.Alpha level 0.05. Md = median; M = mean; SD = standard deviation; ERP = exposure
with ritual prevention; MCT = metacognitive therapy; CY-BOCS = Children’s Yale-Brown Obsessive Scale; CDI = Child Depression Inventory (German version).
The ERP treatment was similar to the published manual by
age, duration of complaints, IQ test scores, and the scores of the
March and Mulle [32] in combining ERP with narrative therapy.
CY-BOCS and CDI before treatment were compared using the
In contrast to this manual, however, no anxiety management tech-
Mann-Whitney U test. The CY-BOCS total score as the primary
niques (such as relaxation training) were applied. In cases where
outcome measure and the CDI T score were compared at pretreat-
the motivation for ERP began to decrease, home-based contingen-
ment, post-treatment, and follow-up by calculating the nonpara-
metric Wilcoxon paired rank sum test for every single treatment
MCT was based on techniques described by Salkovskis [10] and
group. Using the Statistical Package for Social Sciences for Win-
Wells [11, 12] , adapted by the ﬁ rst author for children and adoles-
dows (SPSS) version 11.0, all hypotheses were examined at an alpha
cents. They were grossly comparable with already published cogni-
level of 0.05. Furthermore, the percentage of improvement and the
tive interventions for adolescents with OCD [13–15] . The main
effect sizes were evaluated using Cohen’s d [33] . Due to the small
differences between the two manuals were the interpretation of ob-
sample size, the effect sizes were corrected as recommended by
sessions and the presumed working mechanism: in ERP, obsessions
were conceptualized as meaningless and metaphorically described as ‘brain hiccups’ [32] . Therapy was explained to work by habitu-ation. In MCT, obsessions were conceptualized as revealing the personal values and the deepest fears of the patient. Therapy aimed
at challenging metacognitive appraisals (metacognitive restructur-ing) and changing metacognitive strategies (e.g. from suppressing
Comparability of the Treatment Groups
thoughts to permitting/accepting them). Following Wells [12] , in
Both treatment groups were comparable regarding
this metacognitive framework ERP could be utilized as behavioral
their age, duration of complaints, IQ test scores, and de-
experiment intended to challenge dysfunctional metacognitions, but not in an intensive, repeated, or habituation-oriented manner.
pression scores ( table 2 ). The patients in the MCT condi-
Accordingly, MCT patients were not encouraged to do ERP as
tion had signiﬁ cantly higher CY-BOCS scores before
homework. Details of the 5 MCT patients and their treatment can
Statistical Analysis Because of the small sample size only nonparametric tests were
All patients showed a signiﬁ cant decrease in OCD
used. To examine the comparability of the two treatment groups,
symptom severity from pre- to post-treatment assess-
Fig. 1. CY-BOCS total scores for each pa-tient treated with exposure and response prevention at pre- and post-treatment and at follow-up 3 months and 2 years after treatment; range 0–40. Fig. 2. CY-BOCS total scores for each pa-tient treated with metacognitive therapy at pre- and post-treatment and at follow-up 3 months and 2 years after treatment; range 0–40.
ments ( ﬁ g. 1, 2 ). In the ERP condition, the CY-BOCS in the MCT group. Given that an improvement of more total scores decreased from 20 to 1 (z = –2.032, p = 0.042).
than 30% is deﬁ ned as success [35] , all 10 patients can be
In the MCT condition, the CY-BOCS total scores de-
considered as responders in both treatment conditions.
creased from 26 to 6 (z = –2.032, p = 0.042).
The corrected effect sizes on the CY-BOCS were 2.2 for
In both groups, depression scores tended to decrease
the ERP condition and 2.92 for the MCT condition. Ac-
from pre- to post-treatment assessments, but the differ-
cording to the criteria of Cohen [33] , both effect sizes were
ences were not statistically signiﬁ cant. CDI T scores de-
creased from 50 to 38 (z = –1.512, p = 0.131) in ERP and from 53 to 41 (z = –1.461, p = 0.144) in the MCT condi-
Treatment Effects after 3 Months
tion. However, the scores were already in the average
At the 3-month follow-up, treatment gains were main-
tained. No signiﬁ cant differences emerged in the CY-
The average treatment duration was 13 sessions for BOCS scores when compared to post-treatment (ERP:
ERP (mean = 13.0; SD = 6.04) and 9 sessions for MCT
z = –0.535, p = 0.593; MCT: z = –0.677, p = 0.498). All
(mean = 10.2; SD = 3.3). There was no signiﬁ cant differ-
but one (metacognitively treated) patient were fully re-
ence in treatment duration between the two groups (U =
At the 2-year follow-up, 4 out of 5 patients in the ERP
Computing improvement rates across treatment in the
condition and all 5 MCT patients could be assessed. Im-
two groups showed a mean improvement in the CY-
provements in the CY-BOCS were maintained, i.e., no
BOCS total score of 89.6% for the ERP group and of 75%
signiﬁ cant differences emerged between post-treatment
Metacognitive Therapy for Pediatric OCD
and the 2-year follow-up (ERP: z = 0.000, p = 1.000; out of these 13 studies, some children and adolescents MCT: z = –0.816, p = 0.414).
received concomitant serotonin reuptake inhibitors/se-lective serotonin reuptake inhibitors pharmacotherapy
Diagnostic Status and Utilization of Therapy during
without controlling for the speciﬁ c effects of combination
therapy. In the present study, no patient received con-
Based on the structured interview (Kinder-DIPS), all
comitant pharmacotherapy. Hence, improvements in
5 patients in the ERP condition and 4 out of 5 patients
symptom severity can be attributed to the psychothera-
in the MCT condition did not fulﬁ l the DSM-IV/ICD-10
peutic interventions. In addition, only a few studies com-
prised a follow-up assessment and if they did, the dura-
In the ERP group, 1 patient received 6 booster sessions
tion of follow-up in previous studies ranged from 3 to 9
of ERP because of recurring OCD symptoms. At the 2-year
months. In the present study, follow-up assessments were
follow-up, he was fully recovered. Another one received 13
conducted after 3 months and after 2 years, thus demon-
booster sessions because of recurring OCD symptoms ac-
companied by motor tics and ADHD symptoms. At fol-
Since MCT included a metacognitively modiﬁ ed ver-
low-up, he showed subclinical compulsive symptoms.
sion of ERP one could argue that MCT actually works by
In the MCT group, 1 patient obtained 2 MCT booster
ERP. However, only 1 MCT patient received this kind of
sessions because of recurring obsessions shortly after the
ERP in only 1 session. Thus, it can be ruled out that MCT
3-month follow-up. At the 2-year follow-up, she was fully
recovered. One further patient received 15 booster ses-sions and additional pharmacotherapy (sertraline 50 mg/
day) because of OCD symptoms and motor tics. At fol-
The present study had several limitations. First, thera-
low-up, he fulﬁ lled the DSM-IV/ICD-10 criteria of mild
pists’ factors could not be varied (in 9 out of 10 cases the
ﬁ rst author was the therapist). Hence, it remains unclear to what degree therapist-speciﬁ c versus treatment-specif-ic factors accounted for the therapy success. Further,
Discussion
treatment integrity (i.e., the therapist’s adherence to the treatment protocol) was not assessed.
To the authors’ knowledge, this is the ﬁ rst study test-
The small sample does not allow generalizations to
ing MCT for childhood OCD and the ﬁ rst one applying
other children and adolescents with OCD, especially
two different psychotherapeutic approaches. Both MCT
those with a severer or chronic disorder, or to those of
and ERP produced signiﬁ cant and robust reductions in
younger age. The youngest patient treated with MCT was
obsessive-compulsive symptom severity. These effects 9 years old. It has yet to be clariﬁ ed at which age MCT were observed during a short time span (13 sessions of can be implemented into treatment. Similar to the pa-ERP and 9 sessions of MCT) and were still observed 2
tients in the previous studies, the patients in the present
years after commencement of the therapy. All patients study suffered from moderate OCD. Further studies are treated with ERP and 4 out of 5 patients treated with required to demonstrate that patients with severer and MCT were (nearly) fully recovered 3 months and 2 years
chronic OCD can beneﬁ t from ERP and/or MCT.
after therapy. Two patients with comorbid Tourette’s
Because of the small sample size and higher symptom
syndrome/ADHD and with tic disorder were in need of
severity (prior to therapy) in the MCT condition, no be-
more intensive therapeutic support after the actual ther-
tween-group differences were analyzed. Larger-scale
apy. This is in accordance with previous ﬁ ndings of a se-
comparisons between MCT and ERP are therefore war-
verer long-term outcome of OCD in the presence of co-
ranted to investigate differences in the efﬁ cacy of the two
Regarding depressive symptoms, the scores declined
after therapy. The calculated differences failed to reach
Clinical Implications and Future Directions
statistical signiﬁ cance, which can be attributed to the
Notwithstanding these limitations, the present study
advocates MCT to be a promising alternative to ERP.
Treatment duration, response rate, and treatment ef-
Thus, it challenges previous ﬁ ndings and recommen-
fects were comparable with previously reported studies dations suggesting that a successful psychotherapy for reviewed elsewhere [3, 38] for both ERP and MCT. In 9
children and adolescents with OCD has to be based on
ERP. Williams et al. [15] pointed out that cognitive in-
treated with a more cognitively oriented therapy. Our im-
terventions – especially the normalizing of intrusive pression was that MCT seems to require a higher level of thoughts – can serve to enable ERP as a treatment strat-
self-reﬂ ection, whereas ERP demands a higher level of
egy. Insofar, metacognitive interventions can be seen as
emotion regulation (especially, coping with anxious
arousal). In future studies, longer follow-up intervals
Larger-scale randomized controlled trials examining should be conducted. Special attention has to be paid to
the short- and long-term effects of MCT are warranted.
children with comorbid tic disorder who may show a
Furthermore, relative efﬁ cacy, indications, and contrain-
poorer outcome (i.e., a need for further interventions/
dications for MCT vs. ERP need to be investigated. Lee
and Kwon [39] speculated that (adult) patients with reac-
If MCT proves to be efﬁ cacious in OCD treatment,
tive obsessions (i.e., obsessions evoked by identiﬁ able
then habituation may not be the only working mechanism
stimuli) might beneﬁ t more from ERP, whereas patients
underlying a successful therapy [40] . The efﬁ cacy of MCT
with autogenous obsessions (i.e., obsessions which enter
may thus lead to further questions as to ‘what really works
consciousness without identiﬁ able stimuli) may be better
References
1 Zohar AH: The epidemiology of obsessive-
10 Salkovskis PM: Understanding and treating
21 Mather A, Cartwright-Hatton S: Cognitive pre-
compulsive disorder in children and adoles-
obsessive-compulsive disorder. Behav Res
dictors of obsessive compulsive symptoms in
cents. Child Adolesc Psychiatr Clin N Am
adolescence: a preliminary investigation. J
11 Wells A: Cognitive Therapy of Anxiety Disor-
Clin Child Adolesc Psychol 2004;33:743–
2 Geller DA, Biederman J, Stewart SE, Mullin
ders. A Practice and Conceptual Guide. Chi-
B, Martin A, Spencer T, Faraone SV: Which
22 Simons M: Exposition mit Reaktionsverhinde-
SSRI? A meta-analysis of pharmacotherapy
12 Wells A: Emotional Disorders and Metacogni-
rung und metakognitive Therapie bei Kindern
trials in pediatric obsessive-compulsive disor-
tion. Innovative Cognitive Therapy. Chiches-
und Jugendlichen mit Zwangsstörungen; the-
der. Am J Psychiatry 2003;160:1919–1928.
3 Barrett P, Healy-Farrell L, March JS: Cogni-
13 Freeston MH: Cognitive-behavioural treat-
23 Wells A, Papageorgiou C: Metacognitive ther-
tive-behavioral family treatment of childhood
ment of a 14-year-old teenager with obsessive-
apy for depressive rumination; in Papageor-
obsessive-compulsive disorder: a controlled
compulsive disorder. Behav Cogn Psychother
giou C, Wells A (eds): Depressive Rumination.
trial. J Am Acad Child Adolesc Psychiatry
14 Shafran R, Somers J: Treating adolescent ob-
24 Beck AT: Depression: Causes and Treatment.
4 Chambless DL, Ollendick TH: Empirically
sessive-compulsive disorder: applications of
Philadelphia, University of Pennsylvania
supported psychological interventions: contro-
the cognitive theory. Behav Res Ther 1998;36:
versies and evidence. Annu Rev Psychol 2001;
25 Cottraux J, Note I, Yao SN, Lafont S, Note B,
15 Williams TI, Salkovskis PM, Forrester EA, All-
5 The Pediatric OCD Treatment Study (POTS)
Team: Cognitive-behavior therapy, sertraline,
appraisal of responsibility during cognitive be-
trolled trial of cognitive therapy versus inten-
and their combination for children and adoles-
havioural treatment: a pilot study. Behav Cogn
sive behavior therapy in obsessive compulsive
cents with obsessive-compulsive disorder: the
Pediatric OCD Treatment Study (POTS) ran-
16 Salkovskis PM, McGuire J: Cognitive-behav-
ioural theory of OCD; in Menzies RG, de Silva
26 Chambless DL, Hollon SD: Deﬁ ning empiri-
P (eds): Obsessive-Compulsive Disorder. The-
cally supported therapies. J Consult Clin Psy-
6 de Haan E, Hoogduin KA, Buitelaar JK, Keijs-
ory, Research and Treatment. Chichester,
ers GP: Behavior therapy versus clomipramine
27 Unnewehr S, Schneider S, Margraf J: Diag-
for the treatment of obsessive-compulsive dis-
17 Purdon C, Clark DA: Meta-cognition and ob-
nostisches Interview bei psychischen Störun-
order in children and adolescents. J Am Acad
sessions. Clin Psychol Psychother 1999;6:102–
Child Adolesc Psychiatry 1998;37:1022–1029.
7 Foa EB, Franklin ME, Kozak MJ: Psychosocial
18 Rachman S, Shafran R: Cognitive distortions:
28 Scahill L, Riddle MA, McSwiggin-Hardin M,
treatments for obsessive-compulsive disorder;
thought-action fusion. Clin Psychol Psycho-
Ort SI, King RA, Goodman WK, Cicchetti D,
Leckman JF: Children’s Yale-Brown Obses-
Richter MA (eds): Obsessive-Compulsive Dis-
19 Cartwright-Hatton S, Wells A: Beliefs about
sive Compulsive Scale: reliability and validity.
order. Theory, Research and Treatment. New
worry and intrusions: the Meta-Cognitions
J Am Acad Child Adolesc Psychiatry 1997;36:
Questionnaire and its correlates. J Anxiety
8 Marks I, Dar R: Fear reduction by psychother-
29 McKay D, Piacentini J, Greisberg S, Graae F,
apies. Recent ﬁ ndings, future directions. Br J
20 Janeck AS, Calamari JE, Riemann BC, Hef-
Jaffer M, Miller J, Neziroglu F, Yaryura-To-
felﬁ nger SK: Too much thinking about think-
bias JA: The Children’s Yale-Brown Obses-
9 Bouvard MA, Milliery M, Cottraux J: Manage-
ing? Metacognitive differences in obsessive-
sive-Compulsive Scale: item structure in an
ment of obsessive compulsive disorder. Psy-
compulsive disorder. J Anxiety Disord 2003;
outpatient setting. Psychol Assess 2003;15:
Metacognitive Therapy for Pediatric OCD
30 Kovacs M: The Children’s Depression Inven-
36 Stewart SE, Geller DA, Jenike M, Pauls D,
39 Lee HJ, Kwon SM: Two different types of ob-
tory (CDI). Psychopharmacol Bull 1985;21:
Shaw D, Mullin B, Faraone SV: Long-term out-
session: autogenous obsessions and reactive
come of pediatric obsessive-compulsive disor-
obsessions. Behav Res Ther 2003;41:11–29.
31 Stiensmeier-Pelster J, Schürmann M, Duda K:
der: a meta-analysis and qualitative review of
40 Rachman S, Shafran R: The mechanisms of
Depressionsinventar für Kinder und Jugendli-
the literature. Acta Psychiatr Scand 2004;110:
behavioral treatment and the problem of ther-
che (DIKJ), ed 2. Göttingen, Hogrefe, 2000.
apeutic failures; in Goodman WK, Rudorfer
32 March JS, Mulle K: OCD in Children and Ad-
37 Wewetzer C, Jans T, Muller B, Neudorﬂ A, Bu-
MV, Maser JD (eds): Obsessive-Compulsive
olescents. A Cognitive-Behavioral Treatment
cherl U, Remschmidt H, Warnke A, Herpertz-
Disorder. Contemporary Issues in Treatment.
Dahlmann B: Long-term outcome and progno-
33 Cohen J: Statistical Power Analysis for the Be-
sis of obsessive-compulsive disorder with onset
41 Hubble MA, Duncan BL, Miller SD: The
havioral Sciences, ed 2. Hillsdale, Erlbaum,
in childhood or adolescence. Eur Child Ado-
Therapy. Washington, American Psychologi-
34 Hedges LV, Olkin I: Statistical Methods for
38 Simons M, Herpertz-Dahlmann B: Psycho-
Meta-Analysis. San Diego, Academic Press,
therapy of compulsive disorder in children and
42 Kazdin AE, Nock MK: Delineating mecha-
adolescents – An overview. Z Kinder Jugend-
nisms of change in child and adolescent thera-
35 Foa EB, Grayson JB, Steketee GS, Doppelt
py: methodological issues and research recom-
HG, Turner RM, Latimer PR: Success and fail-
mendations. J Child Psychol Psychiatry 2003;
ure in the behavioral treatment of obsessive-
compulsives. J Consult Clin Psychol 1983;51: